Ocular toxicity assessment of chronic sildenafil therapy for pulmonary arterial hypertension.

PURPOSE: The aim of this study was to investigate possible functional and structural ocular changes caused by chronic sildenafil therapy to treat pulmonary arterial hypertension (PAH). METHODS: Case-control study included patients with pulmonary arterial hypertension: chronically using sildenafil and without sildenafil treatment. A comprehensive ophthalmologic exam including ectoscopy, extrinsic ocular motility, logMAR visual acuity measurement, contrast sensitivity test, color test, anterior segment biomicroscopy, Schirmer test 1, intraocular pressure, fundus exam under pupil dilation, fundus pictures, time domain and spectral domain optical coherence tomography, ocular Doppler ultrasound were performed. Full-field electroretinography (ERG) was tested for each eye in a subgroup of sildenafil-treated patients. RESULTS: Twenty patients from each group were tested. Bilateral severe keratitis was found in seven (35 %) patients under sildenafil therapy. Lacrimal film break-up time (BUT) was significantly reduced (p = 0.006 respectively) and Doppler ultrasound showed a reduced resistance index of the central retinal artery in the group of sildenafil users (p = 0.019). No diffuse retinal functional abnormalities were found in ERG in treated patients. Visual acuity, contrast sensitivity and color discrimination were normal in both groups. No abnormalities were found in both time-domain and spectral-domain OCT for retinal parameters. CONCLUSIONS: One-third of the treated PAH group showed severe bilateral keratitis. This finding could be related to connective tissue abnormalities usually present in patients with this condition that might be exacerbated with the sildenafil usage. The resistance index of the central retinal artery was diminished in the chronic users group and it could be associated to the vasodilation caused by the medication in the choroidal vessels. An ophthalmic assessment for these patients is recommended to diagnose and treat possible ocular surface and choroidal blood flow abnormalities caused by sildenafil.

Ten-year change in self-rated quality of life in a type 1 diabetes population: Wisconsin Epidemiologic Study of Diabetic Retinopathy.

PURPOSE: To investigate a 10-year change of quality of life and associated factors in a population with type 1 diabetes. METHODS: The Medical Outcome Study Short Form-36 (SF-36) was administered in participants (n = 520) at the 1995-1996 and 2005-2007 examination phases of the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). Physical (PCS) and mental (MCS) component summary scores were calculated. The associations between changes of quality of life and demographic, socioeconomic, and clinical factors were analyzed. RESULTS: PCS score decreased (p < 0.001) and MCS score increased (p < 0.001) after 10 years. The development of cardiovascular disease and the presence of limb amputation were associated with decrease in the PCS score. Those who were working and retired had increased MCS; those who were working and stopped had a decrease in the MCS score. Change in visual acuity and diabetic retinopathy status did not have a significant impact in health-related quality of life scores. CONCLUSIONS: Our findings reinforce the necessity to make every attempt to decrease complications of diabetes in individuals with long-term type 1 diabetes in order to attenuate the diminished quality of life associated with those complications such as cardiovascular disease. Change in employment status, likely due to development of these complications, was also strongly associated with poorer quality of life and suggests the benefits of preventing or decreasing complications to keep people with type 1 diabetes in the workforce.

Vegetal polymer in repair of defects of the orbital floor: an experimental study in rabbits.

BACKGROUND: An experimental study was done to assess the ability of the vegetal polymer miniplates and screws to repair defects of the orbital floor. METHODS: An artificial standard-sized defect was created in the bony floor of right orbit of 45 albino rabbits. The animals were divided into three experimental groups: control group (G1) involving animals with orbital floor defect and no treatment; titanium group (G2) containing animals with orbital floor defect repaired by titanium miniplates and screws; vegetal polymer group (G3) composed of animals with similar orbital floor defects repaired by vegetal polymer miniplates and screws. Throughout the course of the experiment, the animals were clinically evaluated. At 15, 30 and 60 days after surgery, the animals were killed. They were X-rayed immediately after the floor defect and at the moment of sacrifice. Histological and morphometric evaluation of inflammatory reaction and bone healing was done. Data were statistically evaluated. RESULTS: No implants were extruded. Bone consolidation was similar in G2 and G3 and better than in G1 group animals. Inflammatory reaction was most pronounced in animals of G3 15 days after surgery, and it subsided over time. CONCLUSION: Vegetal polymer miniplates and screws induces small inflammatory reaction and had the ability to stimulate bone growth with good integration in the orbital floor defect allowing to consider the vegetal polymer adequate option to treat orbital floor defects. Future studies involving long-term follow-up and biomechanical tests to evaluate material resistance to traction are needed.

Ten-year change in vision-related quality of life in type 1 diabetes: Wisconsin epidemiologic study of diabetic retinopathy.

PURPOSE: To investigate changes of vision-related quality of life during a 10-year period in a population with type 1 diabetes. DESIGN: Prospective cohort study. PARTICIPANTS: Individuals who had their diabetes diagnosed before 30 years of age were considered to have type 1 diabetes (N = 1210). Those who participated in both 14-year (1995-1996) and 25-year (2005-2007) follow-up examinations were included in the current analysis (N = 471). METHODS: Vision-related quality of life was measured with the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). MAIN OUTCOME MEASURES: Changes in vision-related quality of life scores. RESULTS: Loss of 3 lines in the Early Treatment Diabetic Retinopathy Study (ETDRS) chart was the most important factor related to negative changes in the NEI-VFQ-25 scores in our study after controlling for confounders. Most important changes were observed in subscales, such as general vision (-6.46 points), mental health (-10.19 points), role difficulty (-6.90 points), and driving (-10.43 points). Unemployment and the development of long-term complications, such as nephropathy, were also associated with negative changes in some NEI-VFQ-25 subscale scores. However, changes in diabetic retinopathy status were not related to changes in any subscale after 10 years. CONCLUSIONS: Change in visual acuity was the most important factor associated with changes in vision-related quality of life scores in individuals with type 1 diabetes during a 10-year period. Our findings support the necessity of close follow-up of individuals with type 1 diabetes to avoid development of long-term complications and vision loss to improve quality of life.

Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report.

We reported a case of upper eyelid necrosis initially misdiagnosed as a preseptal cellulitis following a hordeolum externum resulting in great damage to the upper eyelid (anterior lamella). The infection was successfully treated with surgical cleansing, drainage, and endovenous antibiotics. Early treatment may avoid severe complications such as eyelid deformity, systemic involvement, and blindness.

Refractive and visual outcomes after Ferrara corneal ring segment implantation at a 60% depth in keratoconic eyes: case series.

PURPOSE: This report addresses refractive, topographic, visual acuity, and optical coherence tomography outcomes 12 months after femtosecond, laser-assisted insertion of Ferrara intrastromal corneal ring segments in keratoconic eyes at a depth of 60%. METHODS: Interventional, prospective, non-comparative case series. We performed femtosecond, laser-assisted insertion of Ferrara intrastromal corneal ring segments in 15 keratoconic eyes. We included patients with documented keratoconus who voluntarily signed informed consents if they had best spectacle-corrected visual acuity ≥0.30 logMAR and corneal thickness ≥400 µm. We excluded patients with previous ocular surgery or corneal curvatures >65 diopters (D). Our main outcome measures were best spectacle-corrected visual acuity and corneal topographic parameters (flattest, steepest and average keratometry [K]), evaluated at baseline and at 1-,3-,6-, and 12-month follow-ups. RESULTS: The mean ± standard deviation baseline uncorrected visual acuity and best spectacle-corrected visual acuity were 1.03 ± 0.46 and 0.42 ± 0.13, respectively; the 12-month mean standard deviation uncorrected visual acuity and best spectacle-corrected visual acuity were 0.72 ± 0.37 and 0.31 ± 0.16, respectively, without significant differences (p=0.05 for both). The mean best spectacle-corrected visual acuity improvements were statistically significant after 3- (p=0.02) and after 6-months (p=0.02). The mean baseline flattest (K1), steepest (K2), and overall keratometries (mean power) were 48.35 ± 3.65 D, 53.67 ± 3.38 D, and 50.84 ± 3.36 D, respectively. The 12-month mean ± standard deviations for flattest-K1, steepest-K2, and overall K were 46.53 ± 3.70 D, 49.83 ± 3.50 D, and 48.12 ± 3.49 D respectively, with statistically significant differences for all three topographic parameters (p=0.01). CONCLUSIONS: Ferrara intrastromal corneal ring segment insertions at a depth of 60% yield satisfactory visual, refractive, and keratometric results in keratoconic eyes.

A case of recurrent keratitis caused by Paecilomyces lilacinus and treated by voriconazole.

We describe here a case of a 21-year-old woman who presented with low visual acuity, pain, and hyperemia in the left eye for 45 days. Her eye had extensive corneal infiltrate, with melting and a central perforation that was glued with cyanoacrylate, but with Seidel (+). She underwent tectonic corneal transplantation, and anterior chamber lavage with subconjunctival infiltration with voriconazole, as well as intracameral injections of amphotericin B. Laboratory tests revealed Paecilomyces lilacinus as the infectious agent. The patient was then maintained with oral voriconazole and eye drops for three months, after which the infection was considered cured. However, in the sixth postoperative month she presented with endothelial rejection, and two weeks later signs of recurrence of the fungal infection. She was treated with two further washes of the anterior chamber and subconjunctival injection of voriconazole, followed by intravenous voriconazole that was replaced with drops after ten days. The infection initially worsened, but then regressed, and at last follow-up, the patient was still infection-free.

Clinically significant macular edema and survival in type 1 and type 2 diabetes.

PURPOSE: To investigate the association of clinically significant macular edema (CSME) and long-term survival in individuals with type 1 and type 2 diabetes. DESIGN: Population-based cohort study. METHODS: The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) is an ongoing prospective population-based cohort study initiated from August 21, 1980 through July 30, 1982 of individuals with diabetes diagnosed at either younger than 30 years of age (younger-onset group; n = 996) or 30 years of age or older (older-onset group; n = 1,370). Stereoscopic color retinal photographs were graded for retinopathy using the modified Airlie House classification scheme. CSME was defined by the Early Treatment Diabetic Retinopathy Study criteria. RESULTS: Prevalence of CSME was 5.9% and 7.5% for the younger- and older-onset groups, respectively. After 20 years of follow-up, 276 younger-onset and 1,197 older-onset persons died. When adjusting for age and gender, CSME was not significantly associated with all-cause mortality (hazard ratio [HR], 1.41; 95% confidence interval [CI], 0.96 to 2.07; P = .08) or ischemic heart disease mortality (HR, 1.14; 95% CI, 0.61 to 2.12; P = .68) in the younger-onset group. In the older-onset group, there was increased all-cause and ischemic heart disease mortality when CSME was present (HR, 1.55; 95% CI, 1.25 to 1.92; P < .01; and HR, 1.56; 95% CI, 1.15 to 2.13; P < .01, respectively), when adjusting for age and gender. After controlling for other risk factors, the association remained significant for ischemic heart disease (HR, 1.58; 95% CI, 1.07 to 2.35; P = .02) among those taking insulin. CSME was not significantly associated with stroke mortality in either group. CONCLUSIONS: CSME seems to be a risk indicator for decreased survival in persons with older-onset diabetes mellitus. The presence of CSME may identify individuals who should be receiving care for detection and treatment of cardiovascular disease.

Amniotic membrane transplantation with narrow-strip conjunctival autograft vs conjunctival autograft for recurrent pterygia.

PURPOSE: To compare amniotic membrane transplantation (AMT) associated with narrow-strip conjunctival autograft vs conjunctival autograft alone for the treatment of recurrent pterygium. METHODS: In this prospective consecutive interventional study, patients with recurrent pterygium were randomly divided into one of 2 groups; group 1: patients undergoing AMT associated with autologous conjunctival graft; and group 2: patients undergoing conjunctival autograft alone. RESULTS: Of the 80 operated eyes included in this study, 39 (group 1, mean patient age 52.1 ± 11.7 SD years) underwent AMT associated with narrow-strip conjunctival autograft and 41 (group 2, mean patient age 45.8 ± 12.9 SD years) underwent conjunctival autograft alone. In group 1, 6 eyes (15.4%) had grade 1 pterygium, 19 eyes (48.7%) had grade 2 pterygium, and 14 eyes (35.9%) had grade 3 pterygium. In the second group, 5 eyes (12.2%) had grade 1 pterygium, 18 eyes (43.9%) had grade 2 pterygium, and 14 eyes (35.9%) had grade 3 pterygium. No statistically significant difference was found between the 2 groups (p = 0.752). Of the 39 eyes in group 1, recurrent pterygium was observed in 7 cases (17.9%). However, of the 41 eyes in group 2, recurrent pterygium was observed in only 4 cases (9.75%). No statistically significant difference was found between the 2 groups (p = 0.2684). CONCLUSIONS: The results of this study indicate that conjunctival autograft alone might be a better surgical choice for the treatment of recurrent pterygia than combining it with AMT; however, this second option provides a good surgical alternative in cases where little conjunctival donor tissue is available.

Keratoconus progression is not inhibited by reducing eyelid muscular force with botulinum toxin A treatment: a randomized trial.

PURPOSE:: To evaluate whether reducing eyelid muscular force through the administration of botulinum toxin type A (BTX-A) to the orbicularis oculi muscles of patients with keratoconus affected corneal parameters indicative of disease progression. METHODS:: In this prospective parallel randomized clinical trial, 40 eyes of 40 patients with keratoconus were randomized into equally sized control and BTX-A groups. Patients in the BTX-A group received subcutaneous BTX-A injections into the orbicularis muscle. The control group received no intervention. Palpebral fissure height, best spectacle-corrected visual acuity (BSCVA), and corneal topographic parameters were evaluated at baseline and at 3-, 6-, 12-, and 18-month follow-ups. RESULTS:: The mean ± standard deviation vertical palpebral fissure heights were 9.74 ± 1.87 mm and 9.45 ± 1.47 mm at baseline in the control and BTX-A groups, respectively, and 10.0 ± 1.49 mm and 9.62 ± 1.73 mm at 18 months, with no significant difference between the groups (p=0.337). BSCVA values were 0.63 ± 0.56 and 0.60 ± 0.27 at baseline in the control and BTX-A groups (p=0.643), and 0.52 ± 0.59 and 0.45 ± 0.26 at 18 months, again with no significant difference between the groups (p=0.452). In addition, there were no statistical differences between the groups at 18 months for the three keratometry topographic parameters: flattest (K1), steepest (K2), and mean (Km) keratometry (p=0.562). CONCLUSION:: BTX-A inhibition of eyelid force generation did not result in detectable changes in corneal parameters in keratoconic patients during 18 months of follow-up.

Use of the Ishikawa diagram in a case-control analysis to assess the causes of a diffuse lamellar keratitis outbreak.

PURPOSE: To identify the causes of a diffuse lamellar keratitis (DLK) outbreak using a systematic search tool in a case-control analysis. METHODS: An Ishikawa diagram was used to guide physicians to determine the potential risk factors involved in this outbreak. Coherence between the occurrences and each possible cause listed in the diagram was verified, and the total number of eyes at risk was used to calculate the proportion of affected eyes. Multivariate analysis was performed using logistic regression to determine the independent effect of the risk factors, after controlling for confounders and test interactions. RESULTS: All DLK cases were reported in 2007 between June 13 and December 21; during this period, 3,698 procedures were performed. Of the 1,682 flap-related procedures, 204 eyes of 141 individuals presented with DLK. No direct relationship was observed between the occurrence of DLK and the presence of any specific factors; however, flap-lifting enhancements, procedures performed during the morning shift, and non-use of therapeutic contact lenses after the surgery were significantly related to higher occurrence percentages of this condition. CONCLUSIONS: The Ishikawa diagram, like most quality tools, is a visualization and knowledge organization tool. This systematization allowed the investigators to thoroughly assess all the possible causes of DLK outbreak. A clear view of the entire surgical logistics permitted even more rigid management of the main factors involved in the process and, as a result, highlighted factors that deserved attention. The case-control analysis on every factor raised by the Ishikawa diagram indicated that the commonly suspected factors such as biofilm contamination of the water reservoir in autoclaves, the air-conditioning filter system, glove powder, microkeratome motor oil, and gentian violet markers were not related to the outbreak.

Incidence of anterior segment neovascularization during intravitreal treatment for macular edema secondary to central retinal vein occlusion.

PURPOSE:: To analyze the effects of injections of intravitreal triamcinolone acetonide (IVTA) and intravitreal bevacizumab (IVB) on the incidence rates of anterior segment neovascularization (ASN) and neovascular glaucoma (NVG) in patients with macular edema secondary to central retinal vein occlusion (CRVO). METHODS:: In this prospective, randomized, double-masked, sham-controlled study, 35 patients with macular edema following CRVO were randomized to intravitreal bevacizumab, intravitreal triamcinolone acetonide, or sham injections during the first 6 months of the study. The primary outcome was the incidence rate of ASN at month 6. The secondary outcomes were the mean changes from baseline in best-corrected visual acuity (BCVA) and central foveal thickness (CFT) on optical coherence tomography over time to month 12. RESULTS:: ASN developed in 8 (22.86%) eyes, including 5 (62.50%) eyes in the sham group and 3 (37.50%) eyes in the IVTA group, during 12 months of fol low-up (p=0.009). BCVA differed significantly (p<0.05) among the groups only at month 1. CFT did not differ significantly (p<0.05) among the groups over 12 months. NVG required surgery and developed in one eye despite laser treatment. CONCLUSION:: Early treatment with intravitreal antivascular endothelial growth factor therapy decreases the rates of ASN and NVG after CRVO.

Impact of botulinum toxin-A on corneal curvature assessed with Scheimpflug and Placido systems.

PURPOSE: To evaluate the effect of eyelid spasm treatment with botulinum toxin-A (BTX-A) on corneal curvature assessed with Scheimpflug (Pentacam) and Placido (Atlas) systems. SETTING: Federal University of São Paulo, São Paulo, Brazil. DESIGN: Prospective interventional case series. METHODS: Patients with hemifacial spasm were evaluated. Steep keratometry (K) and corneal astigmatism (magnitudes and treatment-induced astigmatism) obtained with the Placido and Scheimpflug systems were evaluated before BTX-A application and after 15 days and 2, 3, and 4 months. RESULTS: The study evaluated 48 eyes (24 affected and 24 normal contralateral eyes) of 24 patients. The mean steep K and astigmatism values obtained with the Placido system on the affected side before treatment were 46.91 diopters (D) ± 3.57 (SD) and 2.63 ± 2.46 D, respectively. A significant decrease in steep K (45.14 ± 1.20 D) and astigmatism (1.01 ± 0.58 D) was observed 2 months (P = .003 and P = .0004, respectively) and 3 months (45.64 ± 1.77 D and 1.36 ± 1.31 D, respectively) (P = .03 and P = .01, respectively) after treatment. The Scheimpflug system did not show significant changes in steep K measurements during the 4-month period. The mean astigmatism in the affected eye before treatment was 1.27 ± 0.88 D. A significant reduction was observed at 15 days (1.16 ± 1.16 D) and at 4 months (0.91 ± 0.59 D) (P = .02 and P = .03, respectively). CONCLUSION: The Placido system was more sensitive in detecting a temporary reduction in corneal curvature after eyelid-spasm treatment. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Differences in Corneal Parameters Between Affected and Normal Contralateral Eyes in Patients With Hemifacial Spasm Treated With Botulinum Toxin-A: Outcomes During One Complete Treatment Cycle.

PURPOSE: To investigate possible temporary differences in corneal topographic parameters between affected and normal eyes in patients with hemifacial spasm (HFS) treated with botulinum toxin-A (BTX-A), over the course of 1 treatment cycle. METHODS: This prospective study evaluated corneal topographic differences between affected and normal contralateral eyes during a 4-month period in patients with HFS treated with BTX-A (the duration of action of BTX-A for HFS ranges from 2 to 4 months). Corneal topographic analysis was performed using a conventional topographer (Atlas; Carl Zeiss Meditec, Dublin, CA). Steep K and astigmatism measurements were evaluated before BTX-A application and after 15 days and 2, 3, and 4 months. RESULTS: Twenty-four patients (16 women and 8 men) were evaluated. Steep K [46.9 ± 3.6 diopters (D)] and astigmatism values (2.6 ± 2.5 D) were significantly higher in affected eyes of HFS patients than in nonaffected eyes (45.0 ± 1.4 D and 0.9 ± 0.6 D) before treatment (P = 0.001 for steep K and P = 0.0003 for astigmatism). Astigmatism values also showed significant differences between the affected eye (1.4 ± 0.8 D) and nonaffected eye (0.9 ± 0.6 D) at 4 months (P = 0.006), whereas steep K showed significant differences between both eyes at 15 days (affected eye: 45.6 ± 1.5 D, nonaffected eye: 45.0 ± 1.4 D, P = 0.008), 3 months (affected eye: 45.6 ± 1.8 D, nonaffected eye: 45.1 ± 1.3 D, P = 0.03) and 4 months (affected eye: 45.8 ± 1.2 D, nonaffected eye: 45.1 ± 1.4 D, P = 0.003) after treatment. CONCLUSIONS: The differences in steep K, and especially in astigmatism values, between eyes tended to reduce during the period of action of BTX-A. At 4 months, when the BTX-A effect is considered to be over or very reduced, a significant difference between eyes for both parameters was noted again.

Influence of involuntary eyelid spasms on corneal topographic and eyelid morphometric changes in patients with hemifacial spasm.

BACKGROUND/AIMS: In patients with hemifacial spasm (HFS), treatment relieves eyelid spasms on the affected side, thus changes in corneal topography and eyelid morphometry may be observed after treatment. We aimed to evaluate these parameters during a 4-month period in patients with HFS treated with botulinum toxin A (BTX-A). METHODS: This prospective study evaluated eyelid morphometric and corneal topographic changes in patients with HFS before onabotulinum toxin A application, and after 15 days and 2, 3 and 4 months. RESULTS: 24 patients were treated with BTX-A. On the normal side, the mean palpebral fissure height (PF), interpalpebral surface area (ISA), steep K and astigmatism values were 8.7±1.98 mm, 122.09±39.37 mm2, 44.99±1.45 D and 0.9±0.64 D, respectively, before treatment. A statistically significant difference was not observed in these parameters after treatment (p>0.05). On the affected side, the mean PF, ISA, steep K and astigmatism were 5.5±1.77 mm, 67.68±28.49 mm2, 46.91±3.57 D and 2.63±2.46 D, respectively, before treatment. We observed a statistically significant (p<0.05) increase in the mean PF and ISA on the affected side 15 days (8.36±1.91 mm and 115.92±34.44 mm2, respectively), 2 months (8.18±1.80 mm and 112.22±33.57 mm2, respectively) and 3 months (7.27±1.65 mm and 95.48±27.80 mm2, respectively) after treatment. A statistically significant decrease in steep K and astigmatism was observed at 2 months (45.14±1.20 D and 1.01±0.58 D, respectively) and 3 months (45.64±1.77 D and 1.36±1.31 D, respectively) after treatment. CONCLUSIONS: The results suggest that treatment with BTX-A in patients with HFS leads to eyelid and corneal changes on the affected eye that are significant during the known period of action of the toxin. Thus, caution should be taken when performing ophthalmological examination in patients with HFS, since it may vary according to BTX-A period of action.

Daily Optical Coherence Tomography Examinations after First Antivascular Endothelial Growth Factor Injections: An Interventional Case Series.

Purpose. To evaluate daily spectral-domain optical coherence tomography (SD-OCT) changes in naive-treatment patients with diagnosis of exudative age-related macular degeneration (AMD) treated with intravitreous bevacizumab (1.25 mg), during a 30-day follow-up period. Methods. In prospective, interventional study, SD-OCT was performed daily for 30 days after the first intravitreal injection. The baseline, initial-decrease, minimal, and final central retinal thicknesses (CRTs) were assessed. Results. Nine eyes of nine patients with neovascular AMD were enrolled. The mean baseline CRT was 625.3 ± 182.5 µm, and the mean final CRT was 383.4 ± 163.0 µm (mean difference, 206.1 ± 167.6 µm), a difference that reached significance (P = 0.006). After the first injection, the initial decrease in the CRT was seen as an average of one day after injection (mean CRT, 503.6 ± 189.10 µm; P = 0.0431). The speed of the reduction in the CRT tended to decrease by day 17. The mean CRT was 336.5 ± 105.44 µm and the mean minimal CRT on day 30 was 320.75 ± 96.38 µm. Conclusion. The CRT decreased early after the first injection. We observed a tendency for reductions in the speed with which the CRT decreased by day 17 after the first injection, which may affect retreatment regime.

Comparison of Descemet-On Versus Descemet-Off Deep Anterior Lamellar Keratoplasty in Keratoconus Patients: A Randomized Trial.

PURPOSE: To compare the visual outcomes of Descemet membrane (DM)-on and DM-off after deep anterior lamellar keratoplasty (DALK) using the big-bubble (BB) technique in keratoconus patients. METHODS: In this prospective trial, keratoconic eyes undergoing DALK procedures with the BB technique were randomized into 2 groups: a donor cornea without DM (group 1; 29 eyes) or with DM (group 2; 30 eyes). These groups were compared with respect to best-corrected visual acuity and contrast sensitivity while wearing gas permeable contact lenses and also endothelial cell counts. RESULTS: There were no statistically significant differences between the 2 groups with regard to best-corrected visual acuity and contrast sensitivity using gas permeable contact lenses as well as endothelial cell counts at 3, 6, and 12 months. After 1 year, the mean (±SD) postoperative visual acuity CL (with contact lenses) was 0.05 (±0.01) in the DM-off group and 0.05 (±0.01) in the DM-on group (P = 0.956). Mean postoperative endothelial cell counts were 2425.0 (±123.7) and 2306.7 (79.9), respectively (P = 0.443), and corneal thicknesses were 527.9 (58.3) and 556.6 (47.3), respectively (P = 0.150). During the follow-up period, very few complications occurred and neither group had a predominance of adverse events at 3, 6, 12, or 24 months. CONCLUSIONS: In conclusion, DALK procedures using the BB technique for keratoconus with DM-on or DM-off presented no significant differences regarding the visual outcomes or endothelial cell counts.

Refractive and visual outcomes after Ferrara corneal ring segment implantation at a 60% depth in keratoconic eyes: case series / Resultados refrativos e visuais após a inserção do anel de Ferrara a uma profundidade de 60% em olhos com ceratocone: série de casos

ABSTRACT Purpose: This report addresses refractive, topographic, visual acuity, and optical coherence tomography outcomes 12 months after femtosecond, laser-assisted insertion of Ferrara intrastromal corneal ring segments in keratoconic eyes at a depth of 60%. Methods: Interventional, prospective, non-comparative case series. We performed femtosecond, laser-assisted insertion of Ferrara intrastromal corneal ring segments in 15 keratoconic eyes. We included patients with documented keratoconus who voluntarily signed informed consents if they had best spectacle-corrected visual acuity ≥0.30 logMAR and corneal thickness ≥400 μm. We excluded patients with previous ocular surgery or corneal curvatures >65 diopters (D). Our main outcome measures were best spectacle-corrected visual acuity and corneal topographic parameters (flattest, steepest and average keratometry [K]), evaluated at baseline and at 1-,3-,6-, and 12-month follow-ups. Results: The mean ± standard deviation baseline uncorrected visual acuity and best spectacle-corrected visual acuity were 1.03 ± 0.46 and 0.42 ± 0.13, respectively; the 12-month mean standard deviation uncorrected visual acuity and best spectacle-corrected visual acuity were 0.72 ± 0.37 and 0.31 ± 0.16, respectively, without significant differences (p=0.05 for both). The mean best spectacle-corrected visual acuity improvements were statistically significant after 3- (p=0.02) and after 6-months (p=0.02). The mean baseline flattest (K1), steepest (K2), and overall keratometries (mean power) were 48.35 ± 3.65 D, 53.67 ± 3.38 D, and 50.84 ± 3.36 D, respectively. The 12-month mean ± standard deviations for flattest-K1, steepest-K2, and overall K were 46.53 ± 3.70 D, 49.83 ± 3.50 D, and 48.12 ± 3.49 D respectively, with statistically significant differences for all three topographic parameters (p=0.01). Conclusions: Ferrara intrastromal corneal ring segment insertions at a depth of 60% yield satisfactory visual, refractive, and keratometric results in keratoconic eyes.

RESUMO Objetivos: Este estudo aborda os resultados refrativos, topográficos, acuidade visual e tomografia de coerência óptica, 12 meses após a inserção do segmento de Anel de Ferrara em túnel corneano a 60% de profundidade com o laser de femtosegundo, em pacientes com ceratocone. Métodos: Série de casos não comparativos, prospectivos e intervencionistas. Realizamos a inserção do Anel de Ferrara através de incisão com o laser de femtosegundo em 15 olhos ceratocônicos. Foram incluídos pacientes com ceratocone documentado que voluntariamente assinaram consentimentos informados que tivessem melhor acuidade visual corrigida ≥0.30 tabela logMAR, espessura corneana ≥400µm. Foram excluídos pacientes com cirurgia ocular prévia ou curvatura corneana > 65 dioptrias (D). As principais variáveis medidas foram acuidade visual corrigida e os parâmetros topográficos da córnea (ceratometria mais plana (K1), mais curva (K2) e ceratometria média (K médio), avaliadas no pré-operatório e com 1, 3, 6 e 12 meses de seguimento. Resultados: A média ± desvio padrão da acuidade visual sem correção e acuidade visual corrigida foi 1.03 ± 0.46 e 0.42 ± 0.13, respectivamente; o desvio padrão médio de 12 meses, a acuidade visual sem correção e acuidade visual corrigida foram de 0.72 ± 0.37 e 0.31 ± 0.16, respectivamente, sem diferenças significativas (p=0,05 para ambos). A melhora da acuidade visual corrigida foi estatisticamente significante após 3 meses (p=0,02), e após 6 meses (p=0,02). Os valores médios da linha de base K1, K2, e média (K médio) foram 48,35 ± 3,65D, 53,67 ± 3,38D, e 50,84 ± 3,36D, respectivamente. A média de 12 meses ± desvio padrão para K1, K2, e K médio foi 46,53 ± 3,70D, 49,83 ± 3,50 D, e 48,12 ± 3,49D respectivamente, com diferença estatisticamente significativas para todos os 3 parâmetros topográficos (p=0,01). Conclusões: A inserção do Anel de Ferrara a uma profundidade de 60% no estroma corneano produz resultados visuais, refracionais e ceratométricos satisfatórios em olhos com ceratocone.

Experience with Boston keratoprosthesis type 1 in the developing world.

OBJECTIVE: To report the experience of the Federal University of São Paulo, Brazil, in performing Boston keratoprosthesis type 1 implantation in the developing world. METHODS: We analyzed 30 eyes of 30 patients who underwent Boston type 1 keratoprosthesis surgery between 2008 and 2012 in a prospective interventional study. Preoperative, perioperative, and postoperative parameters were analyzed, including visual acuity (VA), keratoprosthesis stability, and postoperative complications. RESULTS: Preoperative diagnoses were failed grafts in 16 eyes (53.33%), chemical injury in 10 eyes (33.33%) and Stevens-Johnson syndrome in 4 eyes (13.33%). Also, 16 eyes (53.33%) had preoperative glaucoma. Preoperative best corrected VA ranged from 20/400 to light perception. With an average follow-up of 32 months (range 1-55 months), postoperative vision improved to >20/200 in 24 eyes (80%). Postoperative VA was statistically improved compared with the preoperative measurement during all postoperative follow-ups (up to 36 months). During the follow-up period (32 months), retention of the initial keratoprosthesis was 93.3%. The incidence of retroprosthetic membrane was 26.66%. Progression of glaucoma occurred in 7 of 16 eyes (43%). Three patients experienced development of glaucoma after keratoprosthesis implantation. One eye experienced development of infectious keratitis, and 2 eyes had retinal detachment. CONCLUSIONS: Performing Boston type 1 keratoprosthesis in a developing country is a viable option after multiple keratoplasty failures and conditions with a poor prognosis for keratoplasty. Our experience appears similar to major reports in the field from investigators in developed countries. Adjustments to postoperative management must be considered according to the particular location.

A case of recurrent keratitis caused by Paecilomyces lilacinus and treated by voriconazole / Uso do voriconazol na ceratite recorrente causada por fungo Paecilomyces lilacinus

ABSTRACT - We describe here a case of a 21-year-old woman who presented with low visual acuity, pain, and hyperemia in the left eye for 45 days. Her eye had extensive corneal infiltrate, with melting and a central perforation that was glued with cyanoacrylate, but with Seidel (+). She underwent tectonic corneal transplantation, and anterior chamber lavage with subconjunctival infiltration with voriconazole, as well as intracameral injections of amphotericin B. Laboratory tests revealed Paecilomyces lilacinus as the infectious agent. The patient was then maintained with oral voriconazole and eye drops for three months, after which the infection was considered cured. However, in the sixth postoperative month she presented with endothelial rejection, and two weeks later signs of recurrence of the fungal infection. She was treated with two further washes of the anterior chamber and subconjunctival injection of voriconazole, followed by intravenous voriconazole that was replaced with drops after ten days. The infection initially worsened, but then regressed, and at last follow-up, the patient was still infection-free.

RESUMO - Descrevemos aqui um caso de uma mulher de 21 anos que apresentou baixa acuidade visual, dor e hiperemia no olho esquerdo por 45 dias. O olho apresentava infiltrado corneano extenso, com fusão e perfuração central colada com cianoacrilato, mas com Seidel (+). Ela foi submetida a transplante de córnea tectônica e lavagem de câmara anterior com infiltração subconjuntival com voriconazol, além de injeções intracamerais de anfoterecina B. Testes laboratoriais revelaram Paecilomyces lilacinus como agente infeccioso. A paciente foi então mantida com voriconazol oral e colírio por período de três meses, após o qual a infecção foi considerada curada. No entanto, no sexto mês de pós-operatório, ela apresentou rejeição endotelial e, duas semanas após, sinais de recidiva de infecção fúngica. Ela foi tratada com mais duas lavagens de câmara anterior e injeção subconjuntival de voriconazol, seguida por voriconazol intravenoso que foi substituído por gotas após 10 dias. A infecção piorou inicialmente, mas depois regrediu e, no último seguimento, o paciente ainda estava livre de infecção.